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�+ Waste Tire S06ey & Inspection Reports_ Inspection Report Number <br /> ■ :nRi'"b State of California I 4 7 ..... ■ <br /> r:. CIWMB 181(New 04/04) _€}j l <br /> California Integrated Waste Management Board Survey Form Page 1 _; r �� <br /> - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ";; Inspection Details <br /> rt— <br /> TPID- -7 DM <br /> Inspection Type (Fill one) <br /> Site SuffixQ q� (] Q Routine Q Re-inspection Q Referral Q Observation <br /> Local y if Referral,choose referral type(Fill one) - <br /> Identifier: =r CAn -� U a�\� 11Y� � 'k r i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical`A dress <br /> Street LO � <br /> Inspection Date '� <br /> � Trca c � _.- �V o -a <br /> City ,) Stale ZfP Coda Time In Time Out <br /> Business Rep Title OAM O AM <br /> 0 PM <br /> PM <br /> Operational Status:' Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (elVhole/PTS) <br /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> _ O Q Closed Q Altered <br /> GAS Latitude <br /> Q Hauler Q Indoor <br /> __f-I -E_L_- _ 1OQ Inactive Q Truck <br /> - F_--_ :— ___T <br /> Longitude - Q Planned Q OTR QEnd-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments ( i <br /> 40��_f _: <br /> - aa� , c oret, )Ca (-r <br /> ` r <br /> er vc t r mr_� , Vie_ IC -Il c �I N1_d-�— <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �i4, , h 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />